Efficacy and Outcomes of Nitinol Covered Stents for Management of Acute Iatrogenic and Secondary Esophageal Perforation.

INTRODUCTION

The objective of this study was to evaluate efficacy and safety of fully covered nitinol esophageal stent for esophageal perforations.

METHODS

Patients who underwent esophageal stent placement for esophageal perforation between 2009 and 2021 at a tertiary care center were evaluated retrospectively. Patients requiring esophageal repair and/or mediastinal drainage were included. Stable patients with contained perforation were excluded. In each case, a fully covered esophageal stent was placed under fluoroscopic guidance. In most cases, video-assisted thoracoscopy was performed for mediastinal drainage. Leak occlusion and stent position were confirmed with esophagram postoperatively. Outcomes assessed include stent removal timing, successful healing of the leak, need for additional surgical intervention, and survival.

RESULTS

A total of 54 patients underwent stent placement for perforation. The mean age was 63, with 63% (34/54) male preponderance. The most common presenting symptoms were chest pain (48%, 26/54), epigastric pain (20%, 11/54), and shortness of breath (15%, 8/54). Perforations ranged from 1 to 10 cm in length and usually occurred in the lower esophagus (67%, 36/54). Etiology included iatrogenic (44%, 24/54), Boerhaave's (15%, 8/54), oncologic (13%, 7/54), food-induced (11%, 6/54), anastomotic leak (9%, 5/54), and other (7%, 4/54). The majority had concurrent video-assisted thoracoscopy, laparoscopic, or open drainage of the mediastinum (36/54, 67%). 15% (8/54) of patients had stent placed secondarily for perforation/leak. 83% (45/54) of patients had their stents removed with an average removal time of 41 days. 13% (6/46) of patients treated initially with stent required additional surgical intervention. Postoperatively, 10.9% of patients treated primarily with stent (5/46) required an interventional radiology drain and 8.7% (4/46) had stent migration. One migration required a second stent placement, and another required repositioning. 17.3% (8/46) had persistent leak on upper GI study necessitating additional stent (4/8, 50%), percutaneous drainage (2/8, 25%), or resolved spontaneously (2/8, 25%). 95.6% (44/46) survived the hospitalization with median length of stay of 12 days (interquartile range 11). One-year and 2-year survival among patients with a primary stent placement were 84% (26/31) and 79% (19/24) respectively.

CONCLUSIONS

Fully covered esophageal stent placement as the initial form of therapy is a safe and effective for managing acute iatrogenic and secondary esophageal perforations, even in the setting of large perforations and severe sepsis. Endoscopic therapy was generally effective at treating complications.